46 September 2007 ■ dentaltown.com

continuing education

Tissue Managementwith Expasyl; A Keyto RestorativeSuccess

by Dr. Ara NazarianPrivate PracticeTroy, Michigan

Educational objectivesUpon completion of this course, participants should be able to achieve the following:• Understand the dento-gingival complex• Discuss the advantages of preserving the epithelial attachment• Know the protocol of Expasyl placement• Evaluate what conditions warrant placement of this material

AbstractUsing a material called Expasyl, this presentation will provide dentists tech-

niques and tips for predictable soft-tissue management of restorative dentistry rang-ing from porcelain veneers to full mouth rehabilitation. Clinical case examples willbe shown throughout the presentation that will show the versatility of this material.

IntroductionNow is a great time to practice restorative and cosmetic dentistry. Today,

unlike ever before, clinicians and assistants have a variety of restorative materialsfrom which to choose in order to quickly, easily and predictably restore a patient’sdentition to proper form and function. A product that has provided quick, pre-dictable soft-tissue management for crown and bridge procedures as well asrestorative procedures is a material introduced by Kerr (Orange, California)called Expasyl.

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education. You can read the following CE article in

the magazine and go online to www.dentaltown.com

to take the post-test and claim your CE credits,

free-of-charge, or you can mail in your post-test

for a nominal fee. See instructions on page 54.

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Dentaltown.com, Inc. is an AGD PACERecognized Provider. This course offers 2 AGD PACE Continuing Education Credits free-of-charge.

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HistorySulcus opening and hemostasis are two essential perquisites for good access.

Classical gingival excision techniques by laser and primary rotary curettage, cansometimes be painful and lead to damage of the periodontium. Gingival retractiontechniques using cords are often laborious, painful in the absence of anesthesia,and represent a risk of damage to the epithelial attachment.1, 2 Some other draw-backs might include risk of epithelial detachment, risk of irreversible gingivalretraction and excessive bleeding or seeping. Also, the level of the gingival marginis difficult to predict following periodontal healing and therefore may present aes-thetic problems. Some existing products used for hemostasis have shown to beunstable, inhibit bonding, and often leave debris in the sulcus area.3, 4

Expasyl has been developed to deal with these difficulties, saving considerableamount of time for the practitioner and enhancing comfort for the patient.Expasyl utilizes a mechanical and chemical component for sulcus opening andhemostasis. It is comprised of three materials: kaolin, water, and aluminum chlo-ride.5 Expasyl contains white clay (kaolin) to ensure the consistency of the pasteand its mechanical action while aluminum chloride enhances the hemostaticaction. Application of an air water spray will remove the material from the sulcus.

Indications for using Expasyl are essentially whenever hemostasis or sulcusopening (gingival deflection) is required. Procedures may include sulcus openingand hemostasis before taking an impression, restoration of cavities, or prior tobonding or cementing restorations. The Expasyl paste is injected into the sulcus,exerting a stable, non-damaging pressure of 0.1N/nm.3,6 It is important to notethat the approximate measurement of biologic width is 3mm. When Expasyl is leftin place for one minute, this pressure is sufficient to obtain a sulcus opening of

0.5mm for two minutes.4

The product is supplied in reusable capsules. Depending on theclinical situation and number of teeth, four to 10 preparations canbe performed with a single capsule. The reusable capsule can bedecontaminated after each use. The disposable injection canulaallows for bending and shaping for greater access.

Equipment• Capsules• Injection canulas• Applicator

Care after use:• Separate the applicator, capsule and canula.• Discard the injection canula.• Close and decontaminate the capsule.• Clean applicator before disinfection and sterilization.• Store the product separately from the canulas and applicator.

StorageThe paste is very viscous and dependant upon humidity and

temperature. Capsules must be kept around room temperature (20degrees Celsius). If the contents of the capsule are left open to air,its viscosity will increase to where it becomes impossible to inject.To prevent the material from drying up, it is essential to close thecapsule immediately after use. Store the capsules separately from thecanulas and applicator since the paste has aluminum chloride,which could corrode the metal found in canulas and applicator.

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Insertion ProtocolAt the start of injecting the Expasyl material, the canula tip must be braced on

the surface of the tooth with immediate proximity to the gingival edge anglinginto the sulcus. This creates an enclosed space which walls are compromised of thetooth surface, the cross section of the canula tip and the intrasulcular wall. In otherwords, the canula is pushed towards the tooth surface when expressing the mate-rial. It is important to see blanching (from pink to white) of the marginal gingivalto verify that the product has entered the sulcus. As the sulcus expands, the angleof the injection canula tip is increased to maintain contact with the sulcus liningof the gingival edge.

Clinical Case

Case Presentation;A woman in her late 30s presented to the practice dissatisfaction with the

appearance of her smile (Figure 1). She commented that she felt that her existingrestorations were unattractive because of size, shape, and color and that theserestorations were making her look much older than her actual age. She wanted avery white “Hollywood” smile!

Initial diagnostic evaluation consisted of a series of digital images with studycasts, a centric relation bite record and a face bow transfer. The patient had porce-lain veneer restorations present on her maxillary anterior teeth #5-12. Overallvitality and translucency appeared to be compromised with these restorations. Asmile guide book was used to complete the smile analysis necessary for predesign-ing the case. The size and shape of her existing restorations on teeth #8 and 9 weretoo wide, so our goal was to distribute this amongst her other maxillary teeth.Because the patient wanted a very white smile, she decided to restore eight maxil-lary teeth (#5-12) and six mandibular teeth (#22-27).

PreparationWhen informed consent was obtained from the patient, treatment was initiated.

After anesthetic was administered, a crown-removing bur was used to take out themaxillary anterior restorations from #5-12. Utilizing a crown spreader hand instru-ment, the existing restorations were removed with a rotation to dislodge the porce-lain from the underlying tooth. Utilizing Expasyl (Kerr), we not only controlledhemorrhaging, but also achieved gingival retraction (Figure 2). After approximatelytwo minutes in the sulcus, the Expasyl was rinsed off with copious amounts ofwater. Since the patient had a sensitive gag reflex, a very quick-set impression mate-rial was selected (Take One Super-Fast, Kerr) to take the impression. Since her pre-vious restorations had a shade of A-2, the patient desired a whiter smile andselected 010 Bleach shade on the Chromascope (Ivoclar Vivadent).

Laboratory ConsiderationsColor photographs and diagnostic data were also obtained and forwarded to

the laboratory for the fabrication of the final restorations. During the laboratoryphase, the full arch polyvinyl siloxane impressions were used to create a mastermodel on which the restorations would be based. The master model was seg-mented into individual dies that were trimmed and pinned to determine the man-ner by which the final restorations would integrate with the existing soft tissue. Asilicone incisal matrix of the provisionals was created to guide the placement ofincisal effects and edge position in the subsequent ceramic build-up. Additionally,comprehensive color mapping ensured that the definitive aesthetic result of therestorations would meet the patient’s expectations (Figure 3).

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Figure 1: Preoperative smile.

Figure 2: Prepared dentition with gingival retraction.

Figure 3: Porcelain veneer restorations.

Figure 4: Cementation of porcelain veneers.

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continuing education

CementationBefore try-in of the definitive restorations to verify fit and shade, the provi-

sional restorations were removed sequentially, starting from the maxillary anteriorregion. Any remaining cement was cleaned off the prepared teeth and bleedingfrom the gingival tissues controlled with Expasyl (Kerr) paste. After the patientwas shown the retracted view for acceptance, the cementation process was initi-ated. The restorations were treated with phosphoric acid (37 percent) for 20 sec-onds, rinsed, and silanated with a porcelain primer (Kerr). The prepared dentitionwas cleaned with chlorohexidine 2 percent (Consepsis, Ultradent Products, Inc.)for 15 seconds and rinsed to remove any contamination during the temporaryphase. The preparations were treated with Optibond Solo Plus (Kerr) dental adhe-sive according to the manufacturers’ protocol. The adhesive was cured for 10 sec-onds per tooth with L E Demetron II (Kerr) curing light.

Insure white opaque resin cement (Cosmedent) was applied to the inner sur-face of the restorations. The restorations were then placed on the preparations and,while firmly holding the restorations in place, a rubber tip applicator removed allexcess luting cement from the margins (Figure 4 on p. 50). A thin layer of glycerinwas then applied to the margins to prevent an oxygen-inhibiting layer from form-ing. The restorations were tacked at the gingival margin.

While the restorations were still firmly held in place, the restored dentitionwas flossed and any excess luting cement was carefully removed. When most of theexcess cement was removed, the restored dentition was completely light-curedfrom both facial and lingual sides. Any residual cement was removed with a No.15 scalpel or finished with a fine diamond and polishing points. After completepolymerization of the restorations, the occlusion was verified and adjusted. Theoverall health and structure of the soft tissue and restorations was very good. Thepatient was extremely satisfied with her new “Hollywood” smile (Figure 5).

ConclusionExpasyl has proven to be a valuable adjunct for taking accurate impressions.

One significant advantage of Expasyl versus conventional retraction methods is itstime savings. Also, the control of soft-tissue deflection combined with hemostasismeans the quality of final impressions and the fit of laboratory restorations are sig-nificantly improved. Expasyl also creates the ideal environment for bonding offinal restorations. As clinicians, we are always looking for ways of delivering ourservices in an efficient, safe, and productive manner. Expasyl is a great addition toyour armamentarium that allows you to deliver restorations in such a manner.

A special thanks to Burbank Dental Lab for the fabrication of these porcelainveneer restorations. ■

References1. Abdel Gabber F, Aboulazam SF. Comparative study on gingival retraction using

mechanochemical procedure and pulsed YAG laser irradiation. Egypt Dent. J. 1995; 41 (1)1001-1006.

2. Shannon A. Expanded clinical uses of a novel tissue retraction material. Compend ContinEduc Dent. 2002; 23 (1 Suppl): 3-6.

3. Pestacore C. A predictable gingival retraction system. Compnd Contin Educ Dent. 2002;23 (1 Suppl) 7-12.

4. Poss S. An innovative tissue retraction material. Compand Contin Educ Dent. 2002; 23 (1Suppl): 13-17.

5. Ferrari M, Gagidiaco MC, Ercoli G. Tissue management with a new gingival retractionmaterial; a preliminary clinical report. J Prsthet dent. 1996; 75 (3): 242-247.

6. Sharma S, Kugel G. Tissue management: what’s new? Contemp Esthet Rest Pract. 2005: (1)42-43.

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Ara Nazarian, DDS, is a gradu-ate of the University of Detroit-Mercy School of Dentistry inDetroit, Michigan. Upon grad-uation, he completed an AEGDresidency in San Diego, California with theUnited States Navy. He is a recipient of theExcellence in Dentistry Scholarship andAward. Currently, he maintains a privatepractice in Troy, Michigan, with an emphasison comprehensive and restorative care. Hisarticles have been published in many oftoday’s popular dental publications. Dr.Nazarian also serves as a clinical consultantfor the Dental Advisor, testing and reviewingnew products on the market. He has con-ducted lectures and hands-on workshops onaesthetic materials, mini-implants, andrestorative techniques throughout the UntiedStates. Dr. Nazarian is also the creator of theDemoDent patient education model system.He can be reached at 248-457-0500 or atwww.demo-dent.com.

Disclosure: Dr. Nazarian declares being a con-sultant for Kerr Corporation.

Author’s Bio

This CE activity issupported by an unre-stricted grant fromKerr Corporation.

Figure 5: Postoperative smile.

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continuing education

1. What is the hemostatic agent used in Expasyl?a. Ferric sulfateb. Aluminum chloridec. Sodium chlorided. Benzyl chloride

2. Expasyl obtains a sulcus opening of 0.5mm for ________.a. one minuteb. two minutesc. five minutesd. eight minutes

3. What are some drawbacks of existing techniques in tissue retraction?a. Risk of damage to the epithelial attachmentb. Risk of irreversible gingival retractionc. Bleeding and seepingd. All the above

4. Expasyl can be used for the following dental indications:a. Prior to impression takingb. Prior to prosthetic seatingc. Preparation of Class II and V restorationsd. All the above

5. The _________ of the gingival tissues shows that the paste iswell applied.a. whiteningb. darkeningc. yellowingd. red color

6. When using the Expasyl applicator, the tip or canula should bepushed ________ the tooth surface when expressing the material.a. away fromb. towardsc. opposited. all the above

7. Other existing techniques in gingival retraction include__________.a. cord deflectionb. electro or laser surgeryc. rotary curettaged. all the above

8. Which one of the following is not a component of Expasyl?a. Kaolinb. Aluminum chloridec. Ferric sulfated. Water

9. What is the approximate measurement of biologic width?a. 2mmb. 3mmc. 1cmd. .33mm

10. When using Expasyl, the paste must be injected in an enclosedspace which walls are the following:a. Tooth surfaceb. Intra-sulcular wall of the marginal gingivalc. Cross section of the canula tipd. All the above

Post-test

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Licensure: Continuing education credits issued for completion of online CE courses may not apply toward license renewal in all licensing jurisdictions. It is the responsibility of each registrant to verifythe CE requirements of his/her licensing or regulatory agency.

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